Case Reports

Significance of Stuffed Animals at theBedside and What They Can

Reveal About Patients

THEODORE A. STERN, M.D.RACHEL LIPSON GLICK, M.D.

Consultation psychiatrists gather knowledgeby what patients say and don't say, by what

others say, and by what they observe about pa­tients. First impressions are often invaluable.'Objects at the patient's bedside (e.g., photo­graphs, get-well cards, reading materials, andpillow cases brought from home) are commonand can provide useful information about a pa­tient even before the patient is interviewed. Themeaning of these objects to the patient is rarelyinvestigated by the treating clinician.

We present three case reports where stuffedanimals were observed at the bedside and discussthe meaning of the animals for the patients andtheir consultants.

Case Reports

Case I. Ms. A., an obese 30-year-old woman witha history of multiple psychiatric hospitalizations,was transferred from a psychiatric hospital (whereshe was being treated for depressive symptoms) tothe orthopedic surgery service at the MassachusettsGeneral Hospital (MGH) for lumbar disc surgery.Psychiatric consultation was requested to help man­age Ms. A.'s psychotropic medications and to helpher cope following surgery.

Upon entering her room, the consulting psychia­trist immediately noticed a bevy of stuffed koalabears. There were 17 bears in. on, and around Ms.A.'s bed. During the interview, Ms. A. cuddled andspoke to several of the bears. When the psychiatristasked her about the koalas, Ms. A. stated in a child­like voice. "They are my best friends." When askedif the bears had names, she explained that each was

VOLUME 34 • NUMBER 6· NOVEMBER - DECEMBER 1993

named after a psychiatrist she had previously seen.Ms. A. also had a photograph of her current therapisttaped to the wall beside her hospital bed. She re­ported that looking at the picture made her feel"peaceful and contained."

Ms. A.·s interaction with the stuffed bears pro­vided the consultant a poignant clue to the patient'sneed for concrete reminders of important others.Without the bears, she felt isolated and alone. Thepicture of her therapist also helped soothe her lone­liness and probably acted as a much-needed transi­tional object specific to her therapist. 2 Furtherdiscussion confirmed her diagnosis of borderlinepersonality disorder. The psychiatrist devised a treat­ment plan of care that emphasized consistency. struc­ture. and psychotropic medication.

Case 2. Mr. B.• an insecure 50-year-old perpetualgraduate student. entered the cardiac care unit at theMGH following an out-of-hospital cardiac arrestsecondary to ventricular tachycardia. Electrophysio­logic studies were planned. The cardiologist re­quested psychiatric consultation because Mr. B.would only speak to him in a soft but squeaky voicethrough a hand-held basset hound puppet. The cardi­ologist wondered whether Mr. B. was competent togive informed consent for electrophysiologic studies.

Mr. B. spoke to the psychiatric consultant bothdirectly and through his dog puppet. Mr. B.·s

Received January 6. 1992; revised January 31. 1992;accepted May I. 1992. From the Resident Psychiatric Con­sultation Service. Massachusetts General Hospital. and theDepartment of Psychiatry. Harvard Medical School, Boston,MA. Address reprint requests to Dr. Stem. Department ofPsychiatry. Massachusetts General Hospital. Warren Bldg.#605. Boston. MA 02114.

Copyright © 1993 The Academy of PsychosomaticMedicine.

519

Case Reports

woman friend. who was present during the inter­view. explained that they often spoke to each otherthrough animal puppets at home. Mr. B.• thoughchild-like in his style of communication. was able tounderstand the risks and benefits of the planned car­diac procedure. The psychiatrist reassured the cardi­ologist that Mr. B. was competent. A treatment planwas devised that allowed Mr. B. to talk through hispuppet-a style of communication that was lessthreatening to him. As Mr. B. 's fear of death de­creased, he spoke more directly to his caregivers; hewas able to acknowledge that he used the puppets todistance himself from his own anxiety and fear.

Case 3. Mrs. c.. a previously healthy 85-year-oldwoman, came to the medical service for bed rest fol­lowing a painful compression fracture of her spine.Psychiatric consultation was requested to evaluateMrs. C. for depression. She was easy to engage andhad a full range of affect. Although she was sadabout her injury and the possibility that she mightneed to change her living situation. she did not meetcriteria for major depression.

A medium-sized. stuffed white bear with abright red ribbon tied around its neck sat on herbedside table. When the psychiatrist first asked herabout the bear, she was not sure to what he was refer­ring. But then she said. "Oh yes. that. It's a gift fromthe patient who was in the bed next to mine. Shegave it to me when she was discharged yesterday."

In this case. the stuffed animal was a "red her­ring." It held no special meaning for the patient.

Discussion

While stuffed animals are commonly seen onpediatric floors. they are rarely seen at the bed­side of adults. Stuffed animals typically serve asprimary transitional objectsJ or as toys for chil­dren. In adolescence, stuffed animals may act asmodified transitional objects;4 attachment of ad­olescents to stuffed animals is the rule, not theexception. When the meaning of stuffed animalsto psychiatrically hospitalized adolescents wasexplored, it facilitated psychotherapeutic interac­tions.s It is our belief that such exploration leads

References

I. Hackett TP: From lattoos 10 limbic lunes: on lruslingone's intuition in Ihe search for clues 10 illness. Harvard

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to greater understanding of adult patients, in afashion similar to the use of other simple andinexpensive projective tests (e.g., the analysis ofhuman figure drawings).6

Typically, physicians have a visceral reac­tion to the presence of multiple stuffed animals.In the case of Ms. A., there was a mixture ofamazement (at the sheer number of bears pres­ent), amusement, and uneasiness (caused by thebelief that she was lonely and pathetic). Leftunrecognized, such gut feelings might have ledto the provision of inadequate medical care; mostof her caregivers may have wanted to avoid herand her neediness.

After being talked to through a puppet, Mr.B.'s cardiologist knew his patient was strangeand wondered whether he was mentally ill and/orincompetent. Further history showing that Mr. B.and his friend often communicated through pup­pets increased the likelihood that he and/or shewere immature or character-disordered. Toler­ance of this unusual behavior became possibleonly after the behavior could be understood bythe treatment team, and the team was satisfiedthat Mr. B. understood his medical situation.

Bears, like those at the bedside of Mrs. C,are either overlooked by staff or considered cute.Rarely do they generate intense staff reactionsunless they are cradled or cuddled by patients.Then, immaturity and/or regression are consid­ered, and protection or avoidance of the patientmay result.

In and of themselves, stuffed animals at thebedside should not be regarded as pathomnemo­nic for a personality disorder. Rather, their pres­ence should be noted and their significanceinvestigated. From this information, hypothesescan be generated about how a particular patientwith a particular character style might react to hisor her illness. Strategies can then be tailored, assuggested by others,6-9 to manage patient moodand behavior.

Medical Alumni Bullelin 1986; 60:47-492. Adler G. Buie DH: Aloneness and borderline psychopa-

PSYCHOSOMATICS

thology: the possible relevance of child developmentissues. Int J Psychoanal 1979; 60:83-96

3. Winnicott DW: Playing and Reality. New York. BasicBooks. 1971. pp 1-25

4. Humphrey VP: 'The teddy bear girls." Teniary transi­tional objects: a retrospective study of stuffed animalattachments in late adolescence. Dissenation AbstractsInternational 1987; 47:3135B

5. Jaffe SL. Franch K: The use of stuffed animals by hospi­talized adolescents: an area for psychodynamic explora­tion. J Am Acad Child Adolesc Psychiatry 1986;25:569-573

6. Stem TA: The management of depression and anxiety

Case Reports

following myocardial infarction. Mt Sinai J Med 1985;52:623--633

7. Kahana RJ. Bibring GL: Personality types in medicalmanagement. in Psychiatry and Medical Practice in aGeneral Hospital. edited by Zinberg NE. New York.International Universities Press. 1965. pp 108-123

8. Messner E: Autognosis: diagnosis by the use of the self.in Outpatient Psychiatry: Diagnosis and Treatment, editedby Lazare A. Baltimore. MD. Williams & Wilkins. 1979.pp23D--238

9. Geringer ES. Stem TA: Coping with medical illness: theimpact of personality types. Psychosomatics 1986; 27:251-261

Partial Complex Status Epilepticusin a Lithium-Toxic Patient

BARBARA A. SCHINDLER, M.D.

DILIP RAMCHANDANI, M.D.

T he presenting symptoms of lithium toxicityare both well known and confusing in an

emergency setting. The increased number of in­dications for lithium therapy. including organicmood disorders. increases the risk of both inad­vertent and unintentional toxic reactions.

Psychiatrists and emergency room (ER)physicians are aware of the typical clinicalmanifestations of lithium toxicity. which includenausea. vomiting. tremulousness, polyuria, con­fusion, lethargy, and ataxia. I

-3 Symptoms that

may represent lithium toxicity in chronic psychi­atric patients are sometimes attributed to anexacerbation of the underlying psychiatricdisorder. Partial complex status epilepticus, toour knowledge, has not been reported pre­viously as a sequelae of lithium toxicity or as acause of prolonged unresponsiveness in lithium­toxic patients. Our case illustrates the diagnosticdifficulties and confusion engendered by anatypical presentation of a patient with lithiumtoxicity.

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Case Report

Ms. D., a 44-year-old former schoolteacher with ahistory of bipolar disorder. came to the medical ERafter being found "unresponsive" on her apartmentfloor by the city fire rescue service, who were sentthere when she failed to appear at her psychiatricday program for 3 days. She was arousable to verbalstimuli. but unable to remain attentive to an inter­view. The ER physician initially diagnosed her poorresponsiveness as a "catatonic stupor" and arrangedfor admission to the psychiatric service. The psychi­atric consultant in the ER insisted that a urine toxi­cology screen and a serum lithium level be drawn

Received March II. 1992; revised May 6. 1992; ac­cepted June 3. 1992. From the Depanment of Psychiatry.Medical College of Pennsylvania (MCP). Philadelphia. PA.Address reprint requests to Dr. Schindler. Depanment ofPsychiatry. MCP. 3300 Henry Avenue. Philadelphia. PA19129.

Copyright © 1993 The Academy of PsychosomaticMedicine.

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